Identifying Patients' Support Needs Following Critical Illness

A Scoping Review of the Qualitative Literature

J. King; B. O'Neill; P. Ramsay; M. A. Linden; A. Darweish Medniuk; J. Outtrim; B. Blackwood

Disclosures

Crit Care. 2019;23(187) 

In This Article

Discussion

This review has categorised ICU survivor support needs across the ICU patient recovery trajectory and has shown how they exist, change and adapt over time. Identifying and understanding the overwhelming emotional, physical and cognitive experiences, and the subsequent support needs expressed by people who have had a stay in ICU, is a powerful step towards determining early service intervention as patients make their journey from ICU to regaining independence at home.

Our scoping review confirms that patients' support needs are undoubtedly multifaceted and complex following critical illness. Patients express various needs at each transition point. In the early phases, instrumental and emotional needs come to the fore reflecting the fundamental human needs for nutrition, hydration, comfort, safety and physical and emotional support. Some support needs persisted and/or evolved across the continuum of recovery, depending upon the level of disability. If not addressed early on, these needs would likely continue and escalate in a later phase of recovery. As patients transitioned into different phases, their support needs followed the pattern of Maslow's hierarchy of needs:[56] requiring safety and security as they transitioned to the ward; needing family support and belonging and needing a sense of esteem as they transitioned towards increased independence from hospital care and the cotton wool blanket of family support. Although we used House's Social Support Needs framework to classify needs,[22] we kept an open mind to capture additional needs. Spiritual needs emerged as an additional category in this population of patients which is unsurprising given the high mortality rates that have been reported in multinational cohort studies for patients during (19%) and after (24%) an ICU admission.[57]

We consider the use of House's classification of needs with the addition of spiritual needs as highly relevant to this patient population. This view is supported by a recent study exploring contributory factors to early-unplanned hospital readmission of ICU survivors and recommending that interventions and service redesign include a strong focus on social support.[58] Contributory factors were inadequate informational (communication between secondary/primary care, hospital discharge planning, medication communication), emotional and spiritual (timing of psychological care, coming to terms with near-death experiences), instrumental (mobility issues and problems with specialist aids/equipment) and appraisal (fragile social support and goal setting) needs.

This review showed that patients were sometimes able to meet their own needs by drawing on previous life experience and this provided them with an element of 'appraisal' not captured by House's original definition, e.g. they showed ability to assess their own internal appraisal as opposed to receiving external appraisal from others.[22] Conceivably, ability to appraise may reflect self-efficacy or greater ability and motivation to manage their own recovery—a concept termed patient activation. While there are various methods for assessing aspects of activation, such as self-efficacy,[59] health locus of control[60] and readiness to change,[61] they focus on predicting single behaviours rather than the broader elements such as knowledge, skills, beliefs and motivation that a patient needs to manage a chronic illness.[62]

Because support needs change at different stages of recovery, a method of identifying greatest need according to the patient's phase of recovery may help to target specific services at appropriate times. Developing a method, tool or questionnaire that could capture individual patient needs at any stage of recovery after ICU would be useful in clinical practice as this could help target care, strategies and services to support each individual and enable optimal provision of support to meet their changing needs. Additionally, services that are not yet available could be identified and established. While there has been consideration for needs assessment and needs-driven care in other populations (e.g. cancer care, coronary artery disease, interstitial lung disease),[63–65] we believe this review could inform a needs assessment tool or questionnaire for critical care survivors.

The strengths of our review include the use of identified frameworks for categorising support needs and recovery phases. The literature on ICU survivorship is quite large; therefore, we focused our search to include qualitative studies about patients' needs. We conducted our search only up to April 2017 and found there were repeating themes within the papers suggesting we had reached data saturation. Our assumption was confirmed by a recent study of contributory factors for readmission of ICU survivors reporting similar patient and system level themes.[58]

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....